Total glossectomy (with or without total laryngectomy) followed by
postoperative radiotherapy remains the principal treatment method for
advanced base of tongue carcinoma. The procedure remains controversial
owing to poor cure rates and the inevitable functional deficits
associated with it. However, even though total glossectomy is a major
surgical procedure that impacts on speech, deglutition and quality of
life, it may offer patients the best chance of cure in many centres,
especially in the developing world.

Methods. We did a retrospective chart review of all patients at
Groote Schuur Hospital, Cape Town, who had undergone total glossectomy,
with or without total laryngectomy, for stage IV squamous cell carcinoma
(SCC) of the tongue between 1998 and 2004.

Results. Eight patients had a total glossectomy performed during
the study period. At 2, 3 and 5 years 63%, 38% and 25% of patients
respectively were alive without disease. No patient required permanent
nasogastric or gastrostomy feeding, and all returned to a full oral
diet. Three of 5 patients who had laryngeal preservation and could be
assessed for speech had intelligible speech. All but 1 patient (88%)
reported pain relief following surgical excision. Perineural invasion
was present in 75%, and 38% had positive resection margins. Five
patients had recurrence, 2 cervical, 1 local, and 2 local and cervical.

Conclusion. Advanced SCC of the tongue is a devastating disease
causing severe pain and disorders of speech and swallowing. Total
glossectomy (with or without total laryngectomy) and postoperative
radiotherapy is a reasonable treatment option, particularly in the
developing world setting. It has cure rates superior to primary
radiotherapy, and provides motivated patients with excellent pain relief
and a reasonable quality of life.

Although chemoradiation has made great strides, it is generally not
an option in the developing world owing to expense, failure of patients
to complete therapy, and inadequate expertise and support to deal with
the consequences and complications of chemoradiation. Furthermore, in
most centres positron emission tomography (PET) to monitor for
recurrence is not available. More than 50% of the world's
population lives in the developing world. Therefore, even though total
glossectomy is a major surgical procedure that impacts on speech,
deglutition and quality of life, it may offer patients the best chance
of cure in many centres.

Aims

The purpose of this study was to determine the applicability of
total glossectomy for treatment of stage IV tongue cancer in a
developing world setting.

Methods

We did a retrospective chart review of all patients at Groote
Schuur Hospital, Cape Town, who had undergone total glossectomy, with or
without total laryngectomy, for stage IV squamous cell carcinoma (SCC)
of the tongue between 1998 and 2004.

Results

Eight patients underwent total glossectomy (Table I). There were 6
males. Ages ranged between 33 and 72 years (mean 50 years). Patient 6
underwent total glossectomy for salvage following failed radiotherapy.
The remaining patients had primary surgery and postoperative
radiotherapy.

Three patients had total glossectomy performed in conjunction with
total laryngectomy for tumour involving the pre-epiglottic space or
larynx. Five patients (62%) had a marginal mandibulectomy, 1 required
segmental mandibulectomy and 1 required partial pharyngectomy. All
patients had bilateral neck dissections (modified neck dissection types
I or II for palpable nodes, and selective neck dissection levels I - IV
for N0 necks). Reconstruction of the oral defect was done with
latissimus dorsi (4) or pectoralis major (2) pedicled flaps, radial free
forearm flap (RFFF) (1) or rectus abdominis free flap (1). All patients
except for patient 6 had postoperative radiotherapy. There were no
immediate postoperative deaths.

Initial postoperative feeding was by nasogastric feeding tube. No
patient required permanent nasogastric or gastrostomy feeding, and all
patients returned to a full oral diet (Table II). Twenty-five per cent
of patients managed a normal diet, 38% a soft diet, 25% thickened fluids
and 12% only liquids.

Three of 5 patients who had laryngeal preservation and could be
assessed for speech had intelligible speech. One returned to full-time
employment. All but 1 of the patients (88%) reported pain relief
following surgical excision.

At 2, 3 and 5 years, 63%, 38% and 25% of patients respectively were
alive without disease. The average survival for T3 tumours was 42 months
and for T4, 34 months. Of the 5 patients with recurrence, 4 had cervical
recurrence and 3 local recurrence. Two of these patients had both local
and cervical recurrence. Of the 4 patients who developed cervical
recurrence, 1 had had pN2, 2 pN1 and 1 pN0 disease.

Of the 3 patients who developed local recurrence, 2 had clear
resection margins, but all 3 had PNI. Of 3 patients with positive
resection margins 2 died, at 24 and 36 months respectively. The 3rd
patient remains tumour free at 60 months.

Discussion

SCC is the most common malignancy affecting the tongue base,
followed by lymphoma and minor salivary gland tumours. (1) The most
important aetiological factors associated with SCC of the oropharynx are
prolonged exposure to tobacco and alcohol. (2) Alcohol and tobacco act
synergistically, resulting in a greater risk than either one alone. (3)
Carcinoma involving the base of the tongue is usually advanced at the
time of initial presentation, because it becomes symptomatic only at an
advanced stage and examination of this area may be quite difficult.
Tumours tend to spread quickly through the deep tongue muscles and
across the midline to involve the entire tongue. Contraction of the
genioglossus muscle may help to propel malignant cells through potential
spaces within the intrinsic tongue muscles and into the lymphatic
system. (1) Tumour spread often occurs posteriorly and inferiorly into
the vallecula, the epiglottis and hence to the supraglottis and
pre-epiglottic space (1) (Fig. 1).

[FIGURE 1 OMITTED]

Sir Donald Harrison described the clinicopathological features of
tongue carcinoma in a landmark article in 1983. (4) He reported a high
incidence of PNI, as well as spread by local microembolisation along
perivascular pathways, producing islands of invasive carcinoma beyond
the reported 'histologically clear' resection margins. He
concluded that aggressive surgery was warranted for advanced tongue
carcinoma. In our series PNI was present in 75% of specimens. Our series
showed a 40% local recurrence rate in cases reported as having
histologically clear margins, but PNI had been present in all
recurrences. PNI might therefore explain the high prevalence of local
recurrence after tongue resections with negative margins (32-36%). (4)

Margins were involved in 38% of our specimens. Although in a
developing world setting we have limited availability of frozen section,
our positive/close margins are similar to that reported by others (13%,
50% and 54%). (5-7) Nevertheless, of the 3 patients with involved
margins, only 1 developed local recurrence, and all 3 patients survived
at least 2 years, with 1 patient still alive after 5 years. It may be
difficult to obtain clear margins in advanced tongue carcinoma, because
it is difficult to clinically assess tumour size within the deep muscles
of the tongue, and to distinguish the thick base of tongue tissue from
tumour. Although a 2 cm surgical margin is desirable for SCC of the
tongue, the adult tongue only measures about 11.5 cm x 6 cm. Hence a
patient with a T3 (4-6 cm) or T4 (>6 cm) carcinoma may require total
glossectomy to obtain adequate margins. (4)

The tongue has rich lymphatic drainage and there is no boundary to
cross over to contralateral lymphatic channels. (4) In our study
cervical metastases were present in 63% of patients, and 25% had
bilateral metastases. This corresponds with reports that approximately
70% of patients with SCC of the base of tongue have cervical metastases
at initial presentation, 20 - 30% of which are bilateral. (1,5,8)

We treat advanced, operable tongue base carcinoma with total
glossectomy followed by postoperative radiotherapy. Reported 3-year
survival following primary surgery with postoperative radiotherapy
varies from 32% to 51% (average 40%), (5,6,8,9) and 5-year survival
rates from 12% to 41% (average 27%).5,7,8,9 Our 2-, 3- and 5-year
survival rates of 63%, 38% and 25% compare favourably with the
literature. We had no immediate postoperative deaths, while other series
reported postoperative mortality rates of 3 - 6%. (7-9) Total
glossectomy can also be used for salvage following primary radiation
failure, with reasonable success. (5) Barry et al. found postoperative
morbidity and functional outcomes to be the same in patients undergoing
primary surgery compared with salvage surgery. (5) The survival rates
for patients undergoing primary surgery were higher than for salvage
surgery, although the results did not reach statistical significance.
(6) Chemoradiation with salvage surgery therefore remains an acceptable
alternative in centres with facilities to monitor closely for
recurrences.

Functional evaluation following total glossectomy includes speech,
swallowing, oral intake and aspiration. (9) Successful speech outcome in
50 - 100% of patients following total glossectomy with laryngeal
preservation has been reported. (10-12) Although our data were
incomplete, all patients who could be assessed and had had laryngeal
preservation had intelligible speech. Successful swallowing in 57 - 100%
of patients has been reported. (7,10-12) All our patients returned to an
oral diet and no patient had clinically significant aspiration. Although
our patients' postoperative diet usually consisted of only liquid
or soft food--similar to reports by others (6) - this represented little
change from the preoperative diet.

Discussion about postoperative morbidity must take cognisance of
preoperative function and quality of life (QOL). (13) Patients with
advanced tongue carcinoma are often debilitated by pain and have
problems with speech and deglutition. Our patients reported significant
pain relief following total glossectomy (88%), as has been reported
elsewhere. (9,13) Ruhl et al. assessed QOL in patients who had undergone
total glossectomy by utilising the performance status scale (PSS) and
QOL questionnaires. (8) Functional assessment using the PSS demonstrated
significant deficits in speech and deglutition. QOL questionnaires
revealed problems with eating, speaking, and socialising. However, the
overall response demonstrated that these patients had adjusted to their
deficits and had a good QOL. It was concluded that total glossectomy can
result in meaningful survival and adequate QOL in selected,
well-motivated patients with good emotional support and access to a
skilled and professional rehabilitation team. (8)

The jury is still out on the survival benefits and morbidity of
primary surgery versus radiotherapy for advanced tongue base SCC.14
Primary radiotherapy has the advantage of organ preservation, but
survival rates have been disappointing for advanced base of tongue SCC.
(15,16) Barrett et al. compared treatment with surgical resection
combined with external beam radiation therapy, external beam radiation
therapy alone, and external beam radiation therapy combined with
interstitial radiation. (16) Although survival with both approaches
remained <50%, local control and survival were better with surgical
resection than with external beam radiation. Functional status was
better in long-term survivors treated non-surgically. (16) Recently
reported overall (52%) and disease-specific (67%) 5-year survival rates
after combined external beam radiotherapy and brachytherapy for stage IV
SCC have been encouraging, (17) but morbidity associated with radical
radiotherapy is not insignificant, and dysphagia requiring long-term
nasogastric or enteral feeding is not uncommon. Robertson et al.
reported good QOL after external beam irradiation followed by
brachytherapy and neck dissection. (15) However, they reported survival
for advanced tongue base cancers treated with above modalities to be
dismal, and only suggested this form of treatment for T1 and T2 tumours
in which preservation of function and QOL was a priority. (15)

We employ a few key surgical steps to maximise functional (speech
and deglutition) outcome of total glossectomy.

Upwardly convex floor of mouth (FOM). The reconstructed FOM must be
upwardly convex in order to prevent saliva and food pooling in the
mouth, and to facilitate oral transport and speech (Fig. 2). This
requires a bulky musculocutaneous flap such as latissimus dorsi and
pectoralis major pedicled flaps, or anterolateral thigh or rectus
abdominis free flaps. As the muscle of the flap will atrophy, the flap
must appear too bulky at the time it is inserted. A fasciocutaneous flap
such an RFFF does not provide adequate bulk. Doing a complete marginal
mandibulectomy and suturing the flap to the gingivobuccal mucosa
obliterates the lateral sulci in the mouth, and further improves
function.

[FIGURE 2 OMITTED]

Reduce aspiration. When the larynx is preserved, take care to
preserve the superior laryngeal nerves and any sensate posterior tongue
mucosa possible. We perform a laryngeal suspension by suspending the
hyoid bone to the mandibular arch, and thereby restore the larynx to its
physiological position in an attempt to reduce aspiration and improve
swallowing. (7)

Preserve larynx. An important decision that impacts on both speech
and swallowing is whether to perform a concomitant laryngectomy. A total
glossectomy with total laryngectomy makes the potential for acquiring
good speech impossible, but has the advantage of preventing aspiration.
When tumour involves the larynx, total laryngectomy is unavoidable.
Harrison suggested that total laryngectomy be performed for most base of
tongue tumours in order to obtain adequate margins. (4) We believe, like
others, that laryngeal preservation is possible as long as the vallecula
and pre-epiglottic space are free of disease. (13) While laryngeal
preservation makes speech possible, the risk of significant aspiration
needs to be considered. Preserving the superior laryngeal nerve in
patients undergoing total glossectomy is the most important factor in
preventing aspiration. (6,18) Good postoperative speech and swallowing
rehabilitation can reduce aspiration even further.

Conclusions

Advanced SCC of the tongue is a devastating disease causing severe
pain and disorders of speech and swallowing. Total glossectomy (with or
without total laryngectomy) and postoperative radiotherapy is a
reasonable treatment option, particularly in the developing world
setting. It has cure rates superior to primary radiotherapy, and
provides motivated patients with excellent pain relief and a reasonable
quality of life.

Presented at the Annual Academic Meeting of the South African
Society of Otorhinolaryngology, Head and Neck Surgery, November 2004,
Port Elizabeth.